Ethical perspectives on surgical video recording for patients, surgeons and society: systematic review

Abstract Background Operating-room audiovisual recording is increasingly proposed, although its ethical implications need elucidation. The aim of this systematic review was to examine the published literature on ethical aspects regarding operating-room recording. Methods MEDLINE (via PubMed), Embase, and Cochrane databases were systematically searched for articles describing ethical aspects regarding surgical (both intracorporeal and operating room) recording from database inception to the present (the last search was undertaken in July 2022). Medical subject headings used in the search included ‘operating room’, ‘surgery’, ‘video recording’, ‘black box’, ‘ethics’, ‘consent’, ‘confidentiality’, ‘privacy’, and more. Title, abstract, and full-text screening determined relevance. The quality of studies was assessed using Centre for Evidence-Based Medicine grading and no formal assessment of risk of bias was attempted given the theoretical nature of the data collected. Results From 1048 citations, 22 publications met the inclusion criteria, with three more added from their references. There was evident geographical (21 were from North America/Europe) and recency (all published since 2010) bias and an exclusive patient/clinician perspective (25 of 25). The varied methodology (including ten descriptive reviews, seven opinion pieces, five surveys, two case reports, and one RCT) and evidence level (14 level V and 10 level III/IV) prevented meaningful systematic grading/meta-analysis. Publications were narratively analysed for ethical thematic content (mainly education, performance, privacy, consent, and ownership) that was then grouped by the four principles of biomedical ethics of Beauchamp and Childress, accounting for 63 distinct considerations concerning beneficence (22 of 63; 35 per cent), non-maleficence (17 of 63; 27 per cent), justice (14 of 63; 22 per cent), and autonomy (10 of 63; 16 per cent). From this, a set of proposed guidelines on the use of operative data is presented. Conclusion For a surgical video to be a truly valuable resource, its potential benefits must be more fully weighed against its potential disadvantages, so that any derived instruments have a solid ethical foundation. Universal, ethical, best-practice guidelines are needed to protect clinicians, patients, and society.


Introduction
The concept of surgery as a spectacle is not new. There is a long and continuing tradition of operative performance being independently viewed 1 . Indeed, since the 19th century 2 , surgeons have performed operations specifically in rooms called 'theatres', initially in front of crowds either standing or in tiered seating. More recently, as modern surgery developed aseptic techniques and environments, as well as defined training curricula 3 , operating rooms (OR) often include viewing areas and screens for trainees and other observers to watch. With the broad move towards minimally invasive surgery with digital cameras and the capability for surgical video display, transmission, and recording, large audiences are now being reintroduced to surgery. Surgeries can now be watched back for surgical (including patient and public) education, training, and development 4 . In conjunction with artificial intelligence (AI) models, surgical video recordings enable the creation of OR black boxes (ORBB) 5,6 that have the potential to further transform the field by providing richer detail than traditional operative notes, with AI promising automatic postoperative analysis and insights and potentially intraoperative decision support 7,8 . Thus, surgical videos now have more interest and value than ever before.
Yet, there are concerns over the ethical and legal implications of surgical video recording and the resulting data processing, both in terms of its sourcing and use. Some legal aspects have been discussed elsewhere [9][10][11][12][13][14] , and both the European General Data Protection Regulation (GDPR) 15 and US Health Insurance Portability and Accountability Act (HIPAA) 16 provide legal frameworks to protect citizen privacy, but ethical considerations have been less formally addressed (although of course ethics and law are often intertwined, such as with regard to privacy and ownership issues). There are methods, however, such as the framework of the principles of biomedical ethics of Beauchamp and Childress 17 (namely respect for beneficence, non-maleficence, autonomy, and justice [8][9][10][11]18 ), which can help to identify, address, and ultimately solve ethical medical dilemmas.
The aim of this systematic review was to examine the published literature on ethical aspects of OR data collected via video and/or audio recording, using the principles of Beauchamp and Childress to categorize perspectives, and consider their consequences for individuals (patients and medical staff) and also the general population. Like all systematic reviews, its purpose was to draw together and analyse the existing evidence base, to identify current best practice and gaps that need to be addressed in the future.

Methods
This systematic review (registered with the international prospective register of systematic reviews PROSPERO 19 -CRD42022348406) was completed in accordance with the PRISMA 20 guidelines.

Study objective
To examine the published English-language literature on ethical aspects in relation to OR data collected via video and/or audio recording, as well as their implications for individual patients and medical staff, as well as the general population.

Search strategy
MEDLINE (via PubMed), Embase, and Cochrane databases were searched from database inception to the present (the last search was undertaken in July 2022). There were no limits or restrictions on the basis of date or language of publication at the time of searching; however, only articles available in English were included in the full-text review. Medical subject headings used in the search included 'operating room', 'surgery', 'video recording', 'black box', 'ethics', 'consent', 'confidentiality', 'privacy', and more (see Table S1 for the complete search strategy). The references of included publications were also searched to ensure completeness.

Eligibility criteria
Surgical audiovisual recording was defined as any recording from intracorporeal recording devices (procedural video), as well as medical device recorders recording the OR and/or the procedure itself (panoramic video), including ORBB 21 and Google Glass 22 technology. Although live surgery broadcasting 13,23-30 and tele-surgery 31,32 were beyond the scope of the specific focus here, they are also relevant areas for similar elucidation. The implications of video recording outside the OR, for example in endoscopy suites and critical care areas, were also excluded. Full inclusion and exclusion criteria are outlined in Table 1. In brief, publications were eligible for inclusion if they included 'ethics' or an ethical aspect (including, but not limited to, benefits, privacy, confidentiality, ownership, and consent) in the title or abstract in relation to surgical videos and data and medical device recorders. Original research (randomized controlled, observational, cohort, case-control, case series, and cross-sectional) studies, as well as reviews and commentaries, published in peer-reviewed journals were included.

Study selection
After the removal of duplicates, titles and abstracts were screened for relevance by two reviewers (R.W. and E.C.K.). R.W. and E.C.K. then reviewed the full-text articles according to the inclusion and exclusion criteria as outlined in Table 1. The text and reference lists of included articles were manually searched for additional articles of interest, which were assessed according to the same outlined inclusion and exclusion criteria. Discrepancies that occurred at the title-and abstract-screening stages were resolved by automatic inclusion. Discrepancies at the full-text stage were resolved by consensus between the two reviewers and, if disagreement persisted, a third reviewer (R.A.C.) was consulted.

Data extraction
Relevant data were collected by a single reviewer (R.W.) using a predefined pro forma. Data were sought on the following items from each included article: study characteristics (title, first author, country of origin, and year of publication), study design, and ethical aspect. The quality of studies was assessed using Centre for Evidence-Based Medicine (CEBM) 33 grading and assessment followed the guidelines of the National Centre for Research Methods on conducting narrative synthesis 34,35 . A publication's perspectives were grouped thematically under one or more of the four principles of biomedical ethics of Beauchamp and Childress: beneficence, non-maleficence, autonomy, and justice [8][9][10][11] . The total number of times each ethical principle was discussed was tallied, taking into account the fact that multiple principles could be discussed in each paper, and the data presented systematically. No formal assessment of risk of bias was attempted given the theoretical nature of the data collected.

Search results
A PRISMA flow diagram of the study selection process is presented in Fig. 1. Following the search strategy, 1048 potentially eligible publications were identified. After removing duplicates, unrelated fields, abstracts without full text, and non-relevant papers, 22 manuscripts met the inclusion criteria, with a further 3 publications being added from their references. Publications were primarily from North America (52 per cent) and Europe (32 per cent), but also came from Australia, Asia, and South America. Publication types included commentaries and surveys/ interviews, as well as descriptive, opinion, and narrative reviews (see Table 2) of greatly varying CEBM quality (see Fig. 2). Given this diversity, it was not possible to formally grade the evidence or to undertake statistical analysis. Included publications were therefore synthesized narratively. Table 3 summarizes the areas of strongest evidence for the use of operative data, which can provide a basic guidance of sorts from this review 34 . In total, from the 25 papers, there were 63 distinct discussions of the principles of Beauchamp and Childress (often publications discussed more than one principle; see Table S2 for more detail). Beneficence was discussed in 22 of 25 publications, comprising 35 per cent of total discussion detail, with non-maleficence, justice, and autonomy being discussed in 17 (27 per cent), 14 (22 per cent), and ten (16 per cent) papers respectively (see Fig. 3). Considerations over confidentiality (15 publications), ownership (11 publications), and consent (9 publications) were also raised frequently.

Beneficence
Benefits discussed included performance (13 publications), education and research (11 publications), transparency and improved patient understanding (7 publications), quality improvement and safety (10 publications), and field advancement through AI (3 publications).

Performance
Positive change in performance was attributed, in general, to post-hoc case review, improvement in technical skill, and the Hawthorne effect. Eight publications discussed the learning and reflective opportunity from re-watching operations 49 . Six discussed how such analysis can improve operative skill (including improved error detection) and one review discussed the use of motion-analysis software and AI to examine and aid improvement 44 . Six also discussed the Hawthorne effect (also known as the 'observer effect'), which is defined as a change in normal behaviour when individuals are aware they are being observed. Four publications 42,46,52 acknowledged that this could have a positive or negative effect, with improvement being possibly attributed to increased accountability, attentiveness, and meticulousness, whereas a negative effect could be due to anxiety, stress, or theatrics. Enhanced performance due to 'Records removed before screening': Duplicate records removed n = 122 Records screened n = 926 Records identified from: Citation searching n = 3 Records identified from databases n = 1048 PubMed n = 273 Embase n = 775 Cochrane n = 0 Records excluded -title and abstract not relevant n = 836 Reports not retrieved n = 9 Reports sought for retrieval n = 3 Reports assessed for eligibility n = 3 Reports not retrieved n = 0 Reports retrieved n = 0 improved intraoperative communication was also discussed 22,55 , as was the use of the recording to optimize OR dynamics 46 .

Education/research
All publications concerning education/research advocated that operative recording could benefit surgical trainees either generally or more specifically through video-based coaching and tele-mentoring 42,44 , intraoperative engagement 22 , and targeted feedback 21 . Two articles discussed the benefits of recording for all theatre staff in learning OR dynamics 42,55 .

Transparency/patient understanding
Seven articles discussed transparency and increased patient understanding as a key benefit of operative data recording 36,40,44,[46][47][48]56 . Six proposed that such recording provides a clear objective record of what happened during surgery instead of relying on memory and self-reported dictation/notes, thus reducing bias in the OR by ensuring that there is a record of all operative steps that might otherwise be missed 57 . Four of the seven articles discussed improved patient understanding, which can lead to more informed health decisions 46 and even help patients come to terms with the emotional trauma of surgery 46 . Recordings may also act as an aid to open disclosure and duty of candour when explaining complications to patients 58 .

Quality improvement/safety
Eight publications specified quality-improvement usefulness through the detection of OR errors, with two publications attributing this to improved documentation and audit 21,39,41,42,44,46,48,50,53,54 . Operative recording allows the types of errors assessed to be broken down into technical (that is surgical steps; discussed in seven publications 21,41,42,48,50,53,55 ) and non-technical (relating to the OR environment, including OR dynamics, human and system factors, radiation safety, and prevalence of distractions; discussed in four publications 21,42,46,53 ) errors, either alone (three publications for technical errors and one publication for non-technical errors) or in combination.

Artificial intelligence to further surgery
One author group discussed how AI can be used to look for patterns associated with success and failure, to identify better surgeons 36 , with another stating that AI access to outcome-linked operative

Non-maleficence
Concerns discussed related to privacy and confidentiality (15 publications; 5 publications discussed privacy alone), storage and security (5 publications), and open discussion (3 publications).

Storage and security
The recommendations for OR recording security ranged from physical, under lock and key, to encryption techniques (two-way hashing mechanism), password protection, and anti-hacking or firewall software with storage media, including physical discs, software platforms, and cloud databases 38,44,47,52,60 . File names should not contain patient identifiers. For example 38 , research groups that need to associate performance analysis with surgical outcomes can use a two-way patient identifier hashing mechanism to encrypt medical record numbers and allow the association between specific patient videos and their outcomes without sharing any sensitive data with a third party 47 .

Autonomy
Respect for patient autonomy was discussed in 10 of the included publications, including implications with regard to consent and data use (9 publications), as well as editing of data (5 publications).

Consent and data use
All of these publications recommended that consent is obtained from patients and three publications 47,52,60 recommended that the surgical team also provide consent for recording. In cases where consent cannot be obtained, one study stressed that recording may not be pursued 42 , whereas two claimed that it can, provided that it is an emergency situation 55 and/or consent is acquired before any use of the data 52 . Three publications suggested that the scope of the data, including potential uses (particularly commercial), must be discussed at the time of consent and that each potential use should be explicitly stated 42,47,52 . In a survey, a majority of interviewees felt recordings should be restricted to medical professionals. Regarding withdrawal of consent, three publications stated this should be possible at any time 52 and should not affect patient care 42,47,52 . No direct comparison was made between the opinions of patients and physicians.

Editing
Much of the utility of operative videos for education, publication, and evaluation 47,52 relies on edits, as otherwise the data would be too large and viewing would be too time-consuming 39 . However, editing and compressing an hours-long operation into a few minutes introduces bias 39,42,47 and is likened by two authors to tampering with the medical record 52 or hiding physician mistakes 40 . Two publications recommended that the original file be maintained 47,52 .

Justice
The principle of the fair treatment of individuals, as well as the equitable allocation of healthcare resources, was discussed in relation to data ownership (11 publications), cost (2 publications), credentialling (5 publications), and distributing surgical knowledge (3 publications).

Ownership
A key ethical and legal topic discussed was that of data ownership. Eleven publications debated who owned the surgical data acquired and their recommendation of stakeholder varied greatly. Two stated that patients own their own video recording 40,55 , while one recommended that they are allowed to view the recording 52 . Four argued for its inclusion in the medical record and, as such, the ownership may fall to the institution in which it was created 44,47,52,56 , but this was considered not necessarily the case if the recording was for quality-improvement initiatives 47 . Three publications argued the opposite, stating that anonymized data should not be included in the medical record 11,38,39 and two suggested no definitive owner 42,54 . One study argued that the surgeon may be entitled to an operative video given that the gestures of the surgery represent the culmination of the surgeon's education and experience 38 . Two of the above recommended that it should be explicit during the consent process whose property the video recording will be 44,52 . Only one proposed shared data ownership between multiple stakeholders and raised the issue of ownership regarding potential monetization 39 .

Cost
In a cross-sectional survey, the cost of OR recording was raised by a minority of subjects 40 . One publication argued the opposite, stating that if recording improves performance and outcomes, then the system overall will be cost saving 36 , although no formal cost-benefit analyses were performed.

Credentialling/reducing bullying/discriminatory behaviours
Improved credentialling of trainees (three publications), reduced discriminatory behaviours (two publications), and better assessment of surgical skill (two publications) were proposed. Four publications suggested that OR recording materially evidences performance and can be used to objectively track a trainee's progress, reducing bias in career advancement 21,36,44,61 . This can also be extended to senior surgeons instead of traditional surrogates (for example outcomes or volumes) 38,44 . OR recording may also reduce derogatory OR behaviour (discussed in two publications) 36,40 .

Distributing surgical knowledge
The use of videos to allow for more even and equitable distribution of surgical knowledge 62 to lower-income countries was discussed, with two publications suggesting that open use of video recording allows new procedures to be better disseminated and ultimately makes surgery better 36,43,52 . One study suggested that audiovisual recording coupled with tele-mentoring would allow expert surgical advice to be given at a distance 43 .

Discussion
Although the premise is old, understanding and advancing surgery through its observation has been recently portrayed as a new field and one which is rapidly expanding due to a new capability to aggregate and store recordings and use automated methods to analyse them 63 . Surgical videos, with their high frame number, contrast, and content, qualify as big data 64 , Table 3 Proposed guidelines on operative data Creation of a video/audio recording should have a clearly stated purpose. This may include educational, research, quality improvement, patient request, or others. Any patient undergoing a procedure that may include recording should be made aware and properly consented. This includes, but is not limited to, the purpose of the recording, the intended audience, and the parts of the procedure recorded. Consent should be able to be withdrawn at any stage. Data should be encrypted and ideally anonymized (although pseudonymized may be needed for certain purposes where access to clinical data via a key may be justified) and stored on secure platforms or servers. Patients, faculty, and staff should be notified that a recording will take place during the procedure and given the opportunity to opt out. If editing is required for visual accuracy or timeliness for a presentation, the alterations should be clearly disclosed to any audience. Data ownership/access rights should be clear at inception and contact details given for future enquiries. All recordings should be protected with the same security and scrutiny that the hospital and physicians use for patients' medical records.

Fig. 3 Ethical themes covered in the 25 included papers
There were 63 distinct discussions based on one of the four principles of biomedical ethics, with the breakdown between beneficence, nonmaleficence, justice, and autonomy being shown in the figure.
which can be analysed by AI 65 . It is hoped that such detailed machine analysis can provide new metrics and identify otherwise hidden patterns indicative of success and failure, giving better insight 66 . Surgery is not unique in looking to recordings to improve quality. For comparison, black box recorders were first made mandatory in the airline industry in 1960 67 and all new cars produced within the European Union from 2022 require 'electronic data recorders' 68 . However, whereas historically medicine and medical ethics have taken a paternalistic approach to the doctor-patient relationship, this has changed dramatically in recent decades. Prompted in part by multiple controversies surrounding instances of this relationship being abused throughout the 20th century 69-71 and previously (for example medical schools procuring human bodies from grave robbers), greater importance is now rightly placed on patient autonomy and shared decision-making. Therefore, it is important to consider deeply how surgical recording sits ethically in the modern era of clinical practice as much as the mere technological capability.
To help with this, as in other areas, the pillars of Beauchamp and Childress can be usefully applied, weighing beneficence against the issues presented in the other pillars. While surgical training (where operative videos may help offset the lower case-volume experience of today's trainee due to changes in working hours, advances in non-surgical management and technologies, and the COVID-19 pandemic, among other factors [72][73][74], quality-improvement measures more generally (which intraoperative recordings can assist by providing a uniquely objective, visual record of events to assist investigations of how errors may have occurred or equally confirm that no error occurred and help with open disclosure, especially where mandated [75][76][77], and surgical-device development (including post-marketing surveillance) are clear areas where targeted quality initiatives addressing both technical and non-technical aspects of surgery can be augmented through the use of surgical videos, such use cases cannot be simply advocated in isolation from patient, practitioner, and societal rights, responsibilities, and obligations. Non-maleficence for instance challenges beneficence if privacy concerns are disrespected and autonomy and justice also need consideration regarding recording consent and the storing, editing, and fair and equitable use of a video, allocation of resources, and ownership respectively. Until all aspects are fully considered, it is premature to conclude, as several publications do 36,39,44,47 , that implementing surgical recording falls already and automatically under a surgeon's professional duty of care. Overall, publications in this systematic review focus more heavily on positive potential and only on the individuals immediately involved (that is patient and clinician privacy) without considering the implications of widespread operative recording (including, for instance, the idea of archival 'hoarding' of graphic recordings-including imagery such as patient genitalia-might seem improper or even shocking to the general public as may the selling of medical data to commercial entities and/or the use of data insights garnered from jurisdictions with different citizen rights from where they are being applied). Further, there seems to be a dichotomy between published opinions regarding privacy between patients and staff, with patients, but not staff, being concerned about their individual privacy, despite evident exposure risks. Also, importantly, all publications found by systematic search were published in the 21st century (and the majority since 2010) and also North America and Europe (84 per cent) were predominant as the origin (similar to a 2021 systematic review that found 94 per cent of 70 380 recordings were similarly originated 78 ). This is possibly because the technological capability is often commercially provided and the perhaps greater potential for commercial exploitation by healthcare practitioners/providers in more technology-driven capitalist economies.
It is clear from this systematic review that data management and ownership are crucial areas for further clarification and research. Legal frameworks that require researchers to make sure that personal data collected from patients and healthcare professionals are used fairly and lawfully, for limited and specifically stated purposes, in an adequate, relevant, and considered manner, and kept safe and secure and stored for no longer than is absolutely necessary 15 are in more common use regarding biological data and video data bring new challenges. Anonymized and sufficiently encrypted data typically do not constitute personal data as, for example, under the European Union GDPR, but the infamous Dinerstein versus Google case illustrates very well the risks of reidentification 79,80 , such as through data triangulation, and data-fusion and new technologies (such as facial recognition and even quantum computing) may pose severe risks for this in the near future. Traditionally, consent for data recording should be able to be withdrawn at any stage, but more sophisticated analytic methods make processed data intrinsic to the methods, making complete removal of such data where the data has already been used (for example in algorithmic training sets) difficult if not impossible.
Data ownership is a much debated concept and term, with many different aspects, ranging from ethical aspects, enshrined in the principles of autonomy, to overlapping legal aspects, ranging from privacy protection and personal rights to intellectual-property rights 80 . Interestingly, privacy laws in Europe already include the caveat that data collected for healthcare quality improvement may not be required to be added to a patient's medical record (if a video is made part of the medical record then access is often grantable under Freedom of Information Acts 81,82 ). If the same holds true for anonymized surgical recordings, a question arises over legal ownership and potential 'secondary'-use restrictions. This is particularly important when the potential commercial use of these data is considered versus other important outputs that need weighing, such as public interest and societal good through better surgery. As the commercial value of 'big data' becomes apparent to the general population, controversies have arisen where medical data generated for research purposes were subsequently utilized for commercial purposes without the consent of the participants 83, 84 . Certainly the idea of possession (whether surgeon, patient, or hospital) ascribing ownership should not be automatically assumed. Another question that arises is whether patients should be allowed to view or hold a copy of their recording? There are many possible reasons why, alongside garnering evidence for potential medical malpractice, including increased transparency in ORs, understanding procedures and practices, and even patients' or their loved ones' recovery from the emotional trauma of surgery 56 . Patient ownership of such material naturally confers similar responsibilities (including in such matters as safe storage and restrictions regarding public sharing), as surgical videos may contain data belonging to others (in contrast to the standard medical record, which only contains information specific to the patient). There are also concerns regarding harm or the risk of misinterpretation in viewing surgical videos, especially perhaps when the outcome is known given that the standard is reasonable competence and not perfection and no precise definition as yet exists as to what represents error versus acceptable variation. To this end, some publications promote a shared ownership model (potentially analogous to a biobank) and/or a catalogued library of the operation, which may prove sufficient for many of the reasons operations may need to be viewed.
There are a number of limitations to this systematic review, mostly relating to the quality of the publications, as discussed above. While societal cost 36,40 and knowledge distribution 36,43,52 were discussed, overall, there was a paucity of literature pertaining to surgical video recording and the general population. Therefore, it was not possible to obtain an adequate estimation of the impact of the ethical implications of OR recording on the general population and society. Ethical considerations are not as amenable to the standard systematic review models predicated on measurable interventions, outcomes, and evidence, and, too often, there is overlap with legal aspects. Nonetheless, this systematic review generally serves the purpose of showing the gaps present in the current literature.
Surgical video recording is a growing reality with great potential, but which also presents ethical concerns. Certain general principles are already clear, yet to make this capability truly beneficial and fully operational, many issues still need to be addressed. With clarity, sincerity of purpose, and a responsible, balanced, proportional approach that takes into account practical realities, the value of this resource can be sustainably realized. While jurisdictions may differ, we as a surgical, scientific, and professional community have a responsibility, not only to apply existing ethical and legal frameworks, but to develop broadly applicable and workable guidelines. Given the complexity of the issues, and noting that many relevant aspects, such as liability and bias, still have to be covered, this will require close collaboration of interdisciplinary and inclusive teams, regulators, and society.

Funding
This work was funded in part by the European Union (Grant Agreement no. 101057321). Views and opinions expressed are, however, those of the authors only and do not necessarily reflect those of the European Union or the Health and Digital Executive Agency. Neither the European Union nor the granting authority can be held responsible for them.